Plantar fasciitis is probably the most common cause of pain under the heel. Symptoms often develop gradually over time, are worse first thing in the morning, but ease off when the foot is warmed up. Treatment includes reducing pain and inflammation, stretching exercises, massage, plantar fasciitis taping and correcting foot biomechanics
- Symptoms & diagnosis
- Causes & anatomy
Plantar Fasciitis Symptoms
Symptoms of plantar fasciitis consist of a gradual onset of pain under the heel which may radiate forwards into the foot. There may be tenderness under the sole of the foot and on the inside of the heel when pressing in. The pain can range from being slightly uncomfortable to acutely painful depending on how bad the injury is.
Pain is usually worse first thing in the morning. This is because the foot has been in a relaxed position all night and the plantar fascia gradually tightens up and shortens. After walking around the pain usually eases as the tissues warm up and stretch out, only to return again in more serious cases, later in the day. This may be also noticeable when sitting for long periods before then starting to walk again.
A professional therapist would undertake a full assessment, including case history, physical examination, biomechanical analysis and may use X-rays or other imaging techniques to diagnose plantar fasciitis. Other heel injuries, particularly bruised heel can have similar symptoms. Below we outline some common differences between plantar fasciitis and bruised heel.
Plantar fasciitis causes & anatomy
What is Plantar fasciitis? The Plantar Fascia or plantar aponeurosis as it is also known as a broad, thick band of tissue that runs from under the heel bone (calcaneus) to the front of the foot. Its function is to provide support to the foot when standing and shock absorption when running. Pain is caused by inflammation or degeneration of the tendon where the fascia originates at the heel. Sometimes a bony growth at the heel, known as a heel spur occurs but not all cases of plantar fasciitis have a heel spur, and many heel spurs have no symptoms.
The condition is traditionally thought to be inflammation, however, this is now believed to be incorrect due to the absence of actual inflammatory cells within the fascia and degeneration is thought to be a more likely cause. It is more common in sports which involve running, dancing or jumping.
Although overuse is usually thought to be the cause of plantar fasciitis there are a number of factors which can increase the likelihood of developing the condition:
Overpronation is where the foot rolls in or flattens. As the foot flattens it stretches the plantar fascia more than normal which increases the strain on the tissues, particularly the insertion into the underneath of the heel
A high arched foot (known as pes cavus) causes an increased strain on the attachment of the plantar fascia to the heel. This kind of foot is often rigid and unable to absorb shock whilst running or adapt to the ground.
Wearing inappropriate footwear such as very flat and unsupporting shoes can increase the likelihood of developing plantar fasciitis. If you are a runner then choosing the correct running shoes for your foot type is essential.
Overweight individuals or those who do a lot of heaving lifting at work will place increased load on the foot increasing the chances of developing heel pain.
Tight muscles are thought to be a risk factor in developing plantar fasciitis. Tight hamstring and gluteal muscles, as well as hip muscle imbalances, are thought to predispose people to plantar fasciitis from the effect they have on foot biomechanics. In particular, tight calf muscles and a tight plantar fascia are thought to be most significant.
Plantar Fasciitis Treatment
Treatment consists of reducing pain and inflammation, stretching the plantar fascia and lower leg muscles, correcting any causes followed by a gradual return to fitness. Heel pain can be very stubborn to treat and often a combination of approaches is best in treating plantar fasciitis.
Reducing pain and inflammation is the first priority of plantar fasciitis treatment. Applying the PRICE principles of protection, rest, ice, compression and elevation is important. Apply ice or a cold therapy wrap to help reduce pain and inflammation. Cold therapy can be applied for 10 minutes every hour if the injury is particularly painful for the first 24 to 48 hours. This can be reduced to 3 times a day as symptoms ease. Ice should not be applied directly to the skin but through a wet tea towel to avoid skin burns. Commercial gel hot and cold packs and wraps are a more convenient method of application.
Plantar fasciitis taping (play video 1), (play video 2) is an excellent way of instantly relieving symptoms. It works by supporting the arch of the foot and unloading some of the strain on the plantar fascia allowing the tissues to heal. It may need to be applied regularly until symptoms resolve but many people notice an immediate improvement.
Protect and support the foot by wearing comfortable shoes or trainers. Hard or flat soled shoes are likely to make symptoms worse. A heel pad or insole may help relieve symptoms in the short term but if biomechanic problems such as a flat arch or overpronation are an issue then orthotic type insoles may be more suitable in the long term to prevent the injury returning.
Stretching exercises can begin as soon as pain allows. A plantar fasciitis night splint is a very effective way of stretching the plantar fascia under the heel. It is worn overnight and helps prevent the arch of the foot tightening up overnight.
What can a professional do?
A professional therapist can make an accurate diagnosis and advise on a full treatment and rehabilitation plan. A doctor may prescribe anti-inflammatory medication such as ibuprofen in the early stages to reduce pain and inflammation, although long term use may inhibit healing. Electrotherapy such as ultrasound or laser treatment may also be used to reduce pain and inflammation.
Plantar fasciitis massage (play video): In the later stages of rehabilitation, deep tissue massage techniques can be applied to help stretch and relax the plantar fascia.
Gait analysis may be done to identify biomechanical foot problems and orthotic inserts prescribed. These help control the position of the heel, reducing
For more stubborn injuries a corticosteroid injection may be given and platelet-rich plasma injections have been shown to be effective. If symptoms do not resolve then surgery is an option but this is rare.
Read more on treatment and rehabilitation.
Do I need surgery?
Surgery is used in around 5% of people whose symptoms do not improve after a minimum of nine months, even after continuous treatment. However, the success rate is still only estimated at around 70-80%. In most cases now a procedure called a plantar fascia release is performed which releases (cuts) between 30 and 50% of the fascia's fibers. This helps to reduce the pull and stress on the bony attachment, as well as the fascia itself. Complications can include nerve damage, fallen arches, infection and ongoing symptoms. Recovery after surgery if successful is around 9 to 12 weeks before the patient may return to work.
Plantar Fasciitis Exercises
Exercises to stretch the plantar fascia and the calf muscles are important. Resting alone may reduce pain and inflammation but if part of the cause is tension in fascia then the injury is likely to recur.
Calf Muscle Stretches
Calf stretches with the leg straight (to target the larger gastrocnemius muscle) and with the knee bent (targeting the lower soleus muscles) can be done 3 to 5 times a day. Hold stretches for up to 30 seconds at a time and they should be done pain-free.
Plantar Fascia Stretch
The plantar fascia stretch is done by pulling the foot and toes upwards aiming to feel a stretch in the arch of the foot. Rolling the foot over a ball can also help stretch underneath the foot.
Strengthening exercises are not normally needed, however scrunching a towel up with the toes can get the small muscles of the foot working.
Read more on plantar fasciitis exercises.
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- Riddle DL, Pulisic M, Pidcoe P et al. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Br 2003;85-A(5):872-7
- Gonnade N1, Bajpayee A2 et al Regenerative efficacy of therapeutic quality platelet-rich plasma injections versus phonophoresis with
kinesiotapingfor the treatment of chronic plantar fasciitis: A prospective randomized pilot study. Asian J Transfus Sci. 2018 Jul-Dec;12(2):105-111
- Malahias MA, Cantiller EB, Kadu VV, Müller S. The clinical outcome of endoscopic plantar fascia release: A current concept review. Foot Ankle Surg. 2018 Dec 23.